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STRATEGIES TO PREVENT INFECTION FOLLOWING OPEN FRACTURES Le Ngoc Quyen, MD PhD Definition Open fractures imply communication between the external environment and the fracture Definition • Four components : - Fractures - Soft tissue damage - Neurovascular compromise - Contamination Open fracture classification Gustilo – Anderson classification Importance of Infection Prevention • High Infection Risk: Open frx expose the internal environment of the body to external contaminants, making them highly susceptible to infections • Potential Complications: Infections can lead to severe complications, such as delayed wound healing, septic nonunion and osteomyelitis • Early Intervention: Early and effective infection prevention measures can significantly reduce the risk of complications and improve the overall prognosis for the patient Risk Factors for Infection Following Open Fractures Severity of soft-tissue injury Extent and type of contamination Timing of treatment Antibiotic prophylaxis Surgical treatment Patient factors Modifiable risk factors Stages of care Initial assessment Primary operations Secondary operations Rehabilitation Transport: It's crucial to transport the patient to a healthcare facility within this timeframe to minimize the risk of infection Immediate Care: The Golden Hour Wound Coverage: Covering the open wound with a sterile dressing as soon as possible helps prevent contamination and the introduction of pathogens Splinting: Immobilizing the fractured limb with a splint or other stabilizing device is essential to minimize movement, which can further damage soft tissues and exacerbate the injury ER management components Antibiotics Tetanus prophylaxis 10 • History and mechanism of injury • Vascular and neurological status • Size of the skin wound • Muscle crush or loss • Periosteal stripping or bone necrosis • Fracture pattern, fragmentation, and/or bone loss • Contamination • Compartment syndrome Surgical Management Debridement Fixation Wound closure Time of surgical debridement - 6-hour rule… timelines are controversial - The patient should not be taken to the OR until medically stabilized - If possible, the patient should be taken to the OR within 24 hours of injury 13 Debridement • is the most important part of treating an open fracture • must be complete, thorough and aggressive • irrigated during debridement to reduce the bacterial population • In cases with significant amounts of dead, or possibly ischemic, tissue, reoperation for additional debridement may be necessary Take an organized approach that precedes in orderly steps through tissue levels: • enlarge the wound for adequate exposure • Only minimal non-viable wound margin need be excised • Define the depths of the wound, and examine it thoroughly • All dead or significantly injured tissue is excised systematically according to tissue layer: subcutaneous tissues, fascia, muscle, bone Irrigation • Reduce the bacterial load • Normal saline • No advantage in adding antiseptic solutions or antibiotics • high-pressure irrigation causes more adverse events • minimum volume : L for type I, L for type II, and 9L for type III injuries • 2nd or 3rd debridement after 24–48 hours if in doubt 16 Fracture stabilization • The selection of the method of fixation remains controversial • Internal fixation (plates and intramedullary nails) - Good tissue envelope (upper limb or femoral fractures) - Soft tissue cover within 48-72 hours • External fixation 17 19 Wound coverage • primary wound closure ongoing research • open wound should be left open (unless articular) • But, early closure if possible 20 21 V.A.C : Vacuum-assisted wound closure 22 Open Wound Care Ongoing wound care and appropriate dressing play a pivotal role in infection prevention •Regular Wound Irrigation: Regular irrigation of • Avoid contamination the wound with sterile saline solution helps • Avoid dessication remove contaminants and reduce bacterial load • Consider special dressing • Antibiotic bead pouch • Vacuum-assisted closure • Close promptly •Sterile Dressings: Dressings must be sterile and changed regularly to maintain a clean environment around the wound Patient factor • Smoking • Obsesity • Diabetic • Significant alcohol use (>14 units per week) • Low albumin (
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